Search PubMed⌕ Search

Biomedical subjects

H Wulf

Publications and source records attributed to H Wulf.

At least 109 records · Page 6Linked to original sources
PubMed1998

[Augmentation of the neuromuscular blocking effect of mivacurium during inhalation anesthesia with desflurane, sevoflorane and isoflurane in comparison with total intravenous anesthesia].

To evaluate the enhancement of mivacurium-induced neuromuscular block by potent inhalational anaesthetic agents, dose-effect curves for mivacurium were determined in 84 patients scheduled for minor elective surgery during anaesthesia with 1.5 MAC (70% N2O) desflurane, sevoflurane and isoflurane and compared with those under total intravenous anaesthesia (TIVA). Acceleromyography (TOF-Guard) and train of four (TOF) stimulation of the ulnar nerve were used (2 Hz every 12 s). Mivacurium was administered in increments of 25 micrograms kg-1 until a depression of T1 > 95% was reached. ANOVA was used for statistical analysis (alpha = 0.05, beta = 0.2). The depression of T1 during potent inhalational anaesthesia was enhanced compared with TIVA. The ED50 and ED95 of mivacurium were 27 +/- 11 (SD) and 58 +/- 26 micrograms kg-1 for desflurane; 28 +/- 10 and 64 +/- 23 micrograms kg-1 for sevoflurane; and 27 +/- 13 and 55 +/- 27 micrograms kg-1 for isoflurane and were significantly lower than the 35 +/- 7 and 71 +/- 20 micrograms kg-1 for TIVA. The duration 25% revealed a significant difference between the volatile anaesthetic groups (10 +/- 2, 11 +/- 3, 11 +/- 3 min respectively) and the TIVA control group (8 +/- 3 min). The recovery index 25/75 and TOFO.80 were significantly prolonged by desflurane, sevoflurane and isoflurane compared with TIVA (RI25/75 9 +/- 4, 9 +/- 4, 10 +/- 5 respectively vs. 5 +/- 2 min; TOFO.80 27 +/- 10, 28 +/- 9, 29 +/- 9 respectively vs. 18 +/- 4 min). We conclude that the neuromuscular blocking effect of mivacurium is enhanced during anaesthesia with desflurane, isoflurane and sevoflurane compared with TIVA. The duration of action and the recovery time are prolonged. The dose of mivacurium used should be reduced if anaesthesia is maintained with volatile anaesthetics.

Adolescent↗
PubMed1998

[Recommendations and guidelines for perioperative pain therapy in Germany].

The management of perioperative and post-traumatic pain in clinical practice is still significantly deficient in Germany as shown in a recently published representative and anonymous survey of 1,000 surgical clinics. Several steps were undertaken to improve the situation: in 1992, an agreement on responsibilities and organization was achieved between the "Berufsverbände" of German Surgeons and of Anaesthesiologists. In 1997, recommendations on the treatment of perioperative and post-traumatic pain were published by the two "Berufsverbände" together with the Scientific Societies of Surgeons and Anaesthesiologists. In 1998, national guidelines based on consensus methods in collaboration with the Association of the Scientific Medical Societies in Germany (AWMF) will be published at the Internet address http://www.uni-duesseldorf.de/WWW/AWMF/.

Analgesics↗
PubMed1997

[Prevention of postherpetic neuralgia: does it exist?].

THEORETICAL CONSIDERATIONS: Several pathophysiological mechanisms may be responsible for initiation and maintenance of chronic postherpetic pain. (1) Peripheral nociceptive fibers can develop abnormal sensitization. Secondary to this, central nociceptive "second-order" neurons in the spinal cord dorsal horn can also be sensitized, i.e. they become hyperexcitable and start responding to non-noxious stimuli. (2) Degeneration of nociceptive neurons may trigger anatomical sprouting of low-threshold mechanosensitive terminals to form connections with central nociceptive neurons and may subsequently induce functional synaptic reorganization in the dorsal horn. According to these mechanisms theoretical possibilities of therapeutical interventions to prevent postherpetic neuralgia are (1) adequate analgesia in the acute phase (analgesics, antidepressants, sympathetic blocks) and (2) prevention of C-fiber degeneration by reducing the inflammatory reaction (antiviral drugs, corticosteroids, neurotrophins). CLINICAL EXPERIENCE: The present clinical trials concerning prevention of postherpetic neuralgia were analyzed. Only for the antiviral drugs have valid clinical studies been performed. Using acyclovir a considerable reduction of acute pain and time to healing could clearly be demonstrated. However, there was no significant effect on prevention of postherpetic neuralgia. The second-generation antiviral drugs valaciclovir and famciclovir may be more effective when applied early in the disease course. Preliminary studies indicate that the early onset of therapy with the antidepressant agent amitriptyline may reduce the incidence of postherpetic neuralgia. These results need to be confirmed in further studies. CONCLUSION: Although there is no clear evidence in favor of a prevention of postherpetic neuralgia for any of the interventions, it is definitely reasonable to perform the best analgesia possible during the acute phase of herpes zoster.

English Abstract↗
PubMed1997

[Local therapy with capsaicin or ASS in chronic pain].

OBJECTIVE: To provide a brief review of the current state of topical treatment with capsaicin or acetylsalicylic acid (ASA) for therapy of chronic pain syndromes. DATA SOURCES: A MEDLINE search was used to find the pertinent literature on "capsaicin" or "ASA" and "chronic pain"; further publications found in these articles were added. CONCLUSIONS: Capsaicin is a white crystalline parent compound of a group of vanillyl fatty acid amines. Because of its highly specific action in neurons it has become an important tool in neuroscience. Because of its effects, it is obvious to try for the therapy of circumscribed neuropathic pain. Capsaicin acts by depleting stores of substance P and other neurotransmitters, resulting in a blockade of a specific group of sensory afferents. The corresponding clinical findings are initial burning and a desensitization of specific C fiber nociceptors after repeated application. The pain relieving potency was observed in various clinical investigations and even in a few controlled, double-blind studies about neuropathic pain syndromes and (osteo)arthritis. In contrast to these findings, a recent study found no significant benefit of capsaicin, probably because this study was the first to use an active placebo. Therefore, and because clinical efficacy and advantages over other therapies have not been demonstrated up to now, capsaicin cannot be classified as standard therapy. It may be a therapeutic option as an alternative or as an adjuvant treatment. Pain reduction was also observed after topical application of ASA/ether mixture in the one and only controlled double-blind study on this issue. Therefore, topical ASA therapy for (post)herpetic neuralgia is mainly based on a few enthusiastic case reports rather than on well founded investigations. Furthermore, the discrimination of local from systemic effects, the toxicological profile of longterm topical treatment, and the mechanism of action has not been evaluated. In conclusion, topical ASA cannot be recommended for routine clinical use at present.

English Abstract↗
PubMed1997

[Do "lefthanders" make better local anesthetics? The relevance of stereoisomerism in clinical practice as shown by new local anesthetics].

S-Ropivacaine is a new, long-acting amide local anaesthetic. It is the first local anaesthetic to be on the market as a single isomer. Its pharmacodynamic and pharmacokinetic profile is similar to that of bupivacaine. In vitro and in vivo experiments have shown ropivacaine to be less cardiotoxic than bupivacaine. When given epidurally, both local anaesthetics are equally effective in producing sensory block, but motor block seems to be less pronounced in the case of ropivacaine. This pharmacodynamic profile suggests that ropivacaine has a greater margin of safety and should be a valuable candidate in applications where motor blockade is to be avoided, e.g. for postoperative epidural analgesia and for epidural analgesia in obstetrics.

Amides↗
PubMed1997

Pathophysiological and clinical aspects of the CO2 pneumoperitoneum (CO2-PP).

Experimental studies demonstrated a severe cardiac load of the CO2 pneumoperitoneum caused by an accelerated after- and a decreased preload. Patients displaying cardiovascular risks are therefore often rejected from laparoscopic surgery. Hence, the pathophysiological changes and the intraoperative risk of the CO2 pneumoperitoneum in high-risk cardiopulmonary patients (NYHA II-III, n = 15) undergoing laparoscopic cholecystectomy are described. The changes in cardiac after- and preload seem to be due to the elevated intraabdominal pressure rather than transperitoneally resorbed CO2 and are reversible by desufflation. In one patient conversion to open operation had to be performed because of a severe drop in cardiac output and right ventricle ejection fraction. Mixed oxygen saturation was predicting intraoperative worsening in this case. The described pathophysiological changes may seem to be well tolerated even in high-risk cardiac patients. Monitoring of hemodynamics should include an arterial catheter line and blood gas analyses. Pharmacologic interventions or pressureless laparoscopic procedures might not be necessary as long as laparoscopic cholecystectomy is performed.

Aged↗
PubMed1997

[Diagnosis and therapy of tracheal rupture after blunt thoracic trauma].

Tracheobronchial ruptures are rare but potentially lifethreatening events. We report on the case of a 34-year-old suicidal unrestrained car driver, who developed subcutaneous and mediastinal emphysema and right-sided haematothorax following blunt thoracic trauma. Fibreoptical inspection of the tracheobronchial system revealed a rupture (approximately 2 cm in length) of the pars membranacea of the trachea ending shortly above the carina. CT-scan confirmed the diagnosis of mediastinal emphysema, tracheal rupture and, in addition, left-sided pulmonary contusion. A repair of the tracheal tear was performed by right-sided thoracotomy using a double-lumen tube. The left-sided double-lumen tube was used postoperatively to achieve respirator ventilation with low pressure on the tracheal lumen and on the suture of the tracheal tear. On the other hand, sufficient airway pressure with PEEP for the left lung showing contusion could be provided, using the endobronchial tube. The postperative course was without complications. The patient was on respiratory support for three days due to his-pulmonary contusion. Following final endoscopic control of the trachea he was discharged from the ICU one week after the trauma. The clinical and radiological signs of tracheobronchial ruptures are discussed (respiratory distress, haemoptysis, cyanosis, localised pain, hoarseness, coughing, dysphagia, stridor, subcutaneous emphysema and pneumothorax, tension pneumothorax, mediastinal emphysema). Fibreoptic bronchoscopy is the present gold standard for confirming the diagnosis. The surgical and anaesthesiological approach to the management of tracheobronchial ruptures is described reviewing the current literature.

Adult↗
PubMed1997

Management of the difficult airway. A case of failed fiberoptic intubation.

BACKGROUND: Fiberoptic intubation is the current gold standard for the management of difficult intubation. Nevertheless, in rare circumstances even fiberoptic intubation fails. METHODS: We describe the case of a female patient suffering from neurofibromatosis Recklinghausen and a giant malignant schwannoma on the neck obstructing the pharynx and compromising respiration. Based on the clinical presentation and the MRI findings, difficulties in airway management were anticipated and fiberoptic intubation of the awake patient was planned. RESULTS: After localizing the vocal cords it was not possible to advance the tube into the trachea due to the severe deviation of the glottis. A decision was made to cancel any further fiberoptic intubation attempts and a conventional tracheotomy was performed under local anaesthesia without problems. CONCLUSION: This case illustrates that even awake fiberoptic intubation has its failure rate, due to inability to visualize the larynx, inability to advance the tube over the fiberscope (as in the present case), or inability to direct the tube towards the larynx. Due to the extreme deviation of the larynx other established techniques for difficult intubation were not deemed appropriate in this case. Therefore, weighing the risks and benefits, a decision was made to perform a tracheotomy under local anaesthesia.

Airway Obstruction↗
PubMed1997

[Pain therapy after thoracotomies--systemic patient-controlled analgesia (PCA) with opioid versus intercostal block and interpleural analgesia].

Both regional analgesia and systemic opioid therapy (e.g. PCA) are commonly used for pain relief following thoracic surgery. Many anaesthesiologists are reluctant to use thoracic epidural analgesia on general surgical wards. Therefore, we investigated in a prospective randomised study the efficacy of intercostal blocks (ICB) or interpleural analgesia (IPA) compared to PCA with systemic opioids (PCA). Following ethics committee approval and informed consent, 45 thoracotomy patients were randomised for postoperative pain management: group 1: intravenous PCA with piritramide (PCA-control), group 2: intercostal blocks of the segments concerned with 5 ml bupivacaine 0.5% at the end of surgery and 6 hours thereafter (ICB), group 3: interpleural analgesia with 20 ml bupivacaine 0.25% applied every 4 hours using a catheter placed during surgery near the apex of the pleural space (IPA). Patients in the ICB and IPA groups were able to obtain additional pain relief by PCA with piritramide. Alternative medication for all groups in case of insufficient analgesia was metamizol. Both regional analgesia groups used significantly less piritramide up to the 3rd (IPA) or 7th (ICB) postoperative day than the control group (p < 0.05). The consumption of metamizol was lower as well (n. s.). No significant differences between the study groups were observed with regard to pain scores (visual analogue scale VAS) at rest, during deep inspiration, coughing or mobilisation. Respiratory parameters as forced vital capacity, forced expiratory volume (1 sec) and peak flow (FVC; FEV1; PF) were reduced significantly following thoracotomy and showed a slow restitution in all three study groups without major inter-group differences. Intercostal blocks and interpleural analgesia significantly reduce opioid demand following thoracotomy and are effective means of postoperative pain management. Nevertheless, in contrast to epidural analgesia, both methods have to be supplemented by, or combined with, systemic analgesics in most patients. On the other hand, compared to epidural analgesia, ICB and IPA are less invasive and easier to manage on general surgical wards.

Adult↗
PubMed1996

Epidural anaesthesia and spinal haematoma.

PURPOSE: Haematoma formation in the spinal canal due to epidural anaesthesia is a very rare but serious complication. This paper presents a comprehensive review of case reports. SOURCE: Sampling of case reports over a 10 yr period, medline-research (1966-1995) and cross-check with former reviews. FINDINGS: Fifty-one confirmed spinal haematomas associated with epidural anaesthesia were found. Most were related to the insertion of a catheter, a procedure that was graded as difficult or traumatic in 21 patients. Other risk factors were: fibrinolytic therapy (n = 2), previously unknown spinal pathology (n = 2), low molecular weight heparin (n = 2), aspirin or other NSAID (n = 3), epidural catheter inserted during general anaesthesia (n = 3), thrombocytopenia (n = 5), ankylosing spondylitis (n = 5), preexisting coagulopathy (n = 14), and intravenous heparin therapy (n = 18). CONCLUSION: Coagulopathies or anticoagulant therapy (e.g., full heparinization) were the predominant risk factors, where-as low-dose heparin thromboprophylaxis or NSAID treatment was rarely associated with spinal bleeding complications. Ankylosing spondylitis was identified as a new, previously unreported risk factor. Analysis of reported clinical practice suggests an incidence of haematoma of 1:190,000 epidurals.

Anesthesia, Epidural↗
PubMed1996

Smaller children have greater bupivacaine plasma concentrations after ilioinguinal block.

We have measured plasma concentrations of bupivacaine after ilioinguinal block in children of different sizes. We studied 14 children with weights 10-15 kg and 17 children with weights 15-30 kg. Each child received 0.5% bupivacaine 0.25 ml kg-1 (1.25 mg kg-1) (Carbostesin, Astra, Germany). Venous blood was obtained before the block (control) and at 5, 10, 15, 20, 30 and 60 min after block. Mean maximal concentration in the 10-15-kg group (1.5 (SD 0.9) mg litre-1, range 0.43-4.0 mg litre-1, at 18 (5) min) was significantly higher (P < 0.05) than that in the 15-30-kg group (0.9 (0.3) mg litre-1 range 0.35-1.34 mg litre-1, at 16 (5) min). In the 10-15-kg group, unexpectedly high (up to 4 mg litre-1) bupivacaine concentrations were observed and often concentrations remained high (> 2 mg litre-1) at 60 min. We conclude that smaller children appear to differ in the pharmacokinetic handling of bupivacaine. The maximum safe plasma concentration of bupivacaine in small children, although not clearly established, is likely to be approximately 4 mg litre-1. We recommend, therefore, that a dose of bupivacaine 1.25 mg kg-1 should not be exceeded in the perioperative period when performing ilioinguinal block in children < 15 kg in weight.

Anesthesia, Inhalation↗
PubMed1996

Effect of transcutaneous electrical nerve stimulation on onset of axillary plexus block.

We examined the effect of high frequency transcutaneous electrical nerve stimulation on the onset of brachial plexus block. Three groups of patients scheduled for surgery of the hand had a local anaesthetic block performed with 40 ml mepivacaine 1.5% using the axillary approach. After injection of the local anaesthetic transcutaneous electrical nerve stimulation was applied for 15 min either to the median nerve or the ulnar nerve; no stimulation was applied in the control group. Before and for 45 min after, the injection of local anaesthetic touch perception, pin prick, motor strength and skin temperature were tested by a blinded investigator in the areas supplied by the median, musculocutaneous, radial and ulnar nerves. There were no differences in the onset of block between the groups. Thus, the frequency-dependent action of local anaesthetics could not be demonstrated.

Adult↗
PubMed1995

Intraperitoneal application of bupivacaine during laparoscopic cholecystectomy--risk or benefit?

We investigated, in a double-blind study, the effects of intraperitoneal local anesthetics during laparoscopic cholecystectomy. In Part A of the study 30 patients received 50 mL saline 0.9% (A 0), bupivacaine 0.125% (A 125), or bupivacaine 0.25% (A 25) intraperitoneally at the end of surgery. Mean maximum plasma concentrations of bupivacaine reached 0.48 mg/L (range 0.15-0.90 mg/L) in Group A 125 and 1.0 mg/L (0.35-2.10 mg/L) in Group A 25 within 15 min (range, 5-30 min). There was no significant difference in pain scores or opioid consumption (patient-controlled analgesia with piritramid): 24, 28, and 13 mg/24 h among the study groups, respectively (not significant). Postoperative respiratory function deteriorated in comparison to preoperative values in all study groups, but the forced vital capacity was significantly more impaired in Group A .25. In Part B, 24 patients received placebo (B 0) or bupivacaine 0.25% (B 25). Postoperative hypoxemic periods (oxygen saturation < 92%) were significantly more frequent in Group B 25. Considering the questionable benefits and the potential risks, we would not recommend the application of intraperitoneal bupivacaine during laparoscopic cholecystectomy.

Anesthetics, Local↗
PubMed1995

The influence of ketanserin or urapidil on haemodynamics, stress response and kidney function during operations for myocardial revascularisation.

The study was performed to investigate the different effects of ketanserin and urapidil on haemodynamics, kidney function and plasma catecholamine and aldosterone levels. Forty male patients scheduled for myocardial revascularisation were assigned at random to two groups: group K received ketanserin, group U received urapidil. Anaesthesia consisted of fentanyl, flunitrazepam and pancuronium. Haemodynamic variables were evaluated at eight predefined time points of the operation. Creatinine and free-water clearance as well as plasma levels of adrenaline, noradrenaline and aldosterone were measured in three different periods of the operation. While the groups showed no clinically relevant differences in the haemodynamic variables and the hormone plasma concentrations, the creatinine clearance in group K was slightly increased in the period after cardiopulmonary bypass. Both ketanserin and urapidil prevented hypertension even in the presence of elevated catecholamine plasma levels during and after cardiopulmonary bypass.

Adrenergic alpha-Antagonists↗
PubMed1994

[Postoperative pain therapy at general nursing stations. An analysis of eight year's experience at an anesthesiological acute pain service].

Despite major advances in knowledge and development of efficient techniques for pain control, many patients on surgical wards suffer from modest to severe pain following surgery or trauma. Therefore, in the University Hospital of Kiel, Germany, an anaesthesiology-based acute pain service (APS) was started in 1985 to improve this situation. Organization of an APS. The anaesthesiologist in training who manages the recovery unit serves as an APS for surgical wards and is supervised by a consultant. The anaesthesists on call are responsible after regular working hours. The activities of the APS are as follows: 1. Induction of sufficient postoperative analgesia in the recovery unit for all surgical patients. 2. Clinical rounds on all patients receiving epidural analgesia (EA), other forms of regional analgesia, or patient-controlled analgesia (PCA) every morning and throughout the day if necessary. 3. Additional consultations for postoperative pain management for other patients on request. 4. Assessment and documentation of the clinical status of the patient, quality of analgesia, and side effects. 5. Writing orders for further treatment. 6. Continuing consultations and informal education for ward nurses, physiotherapists, and surgical staff; formal medical training for ward nurses in postoperative pain management. Activity of the APS. From 1985 to 1992, 1947 patients on normal wards were treated (EA: 1736, PCA: 183). Epidural analgesia was performed using a standard protocol with bupivacaine 0.175%-0.25% infused continuously with top-ups if needed (mean 240 mg/day, range 75-600 mg; median duration 7 days, range 1-53, Table 1). Demand for further treatment was proved by day-to-day withdrawal. Since the introduction of an APS, complications of EA such as hypotension (1985/1986:5.1%; 1987/1992:0.5%, Table 3) and insufficient analgesia due to dislocation or other technical complications could be reduced significantly (Table 3). Dermal infections were seen in 2.6% of patients, with a significantly higher incidence in patients with arteriosclerotic diseases (4.1%). Epidural opioids were used in only 46 selected cases on surgical wards. Nevertheless, 2 cases of marked respiratory depression occurred. The overall risk of complications during postoperative EA could be reduced from 1:11 cases in the first 2 years to 1:20 in the last 6 years since introducing the APS. For other regional procedures (e.g., interpleural analgesia) no complications were recorded. PCA was performed using a standard protocol with tramadol or piritramide without background infusion (Table 6). The loading dose was titrated in the recovery unit.(ABSTRACT TRUNCATED AT 400 WORDS)

Acute Disease↗